All Men are Created Equal

All Men are Created Equal

I love living in Omaha.

Sure, the winters can be miserable (this year being the obvious exception—this global warming thing ain’t so bad, eh?) with snow that falls sideways and potholes the size of national parks in Arizona. The corn fields can be beautiful in the right light but in my mind don’t quite rise to the majesty of the mountains and red rock of my native Utah. Worst of all, in my 8 years here I still haven’t converted to the local religion—Husker worship.

Still, I love this place, and a recent article in the New York Times gave me even more reason. The piece reported on the newest trend among hospitals trying to vie for more pieces of the ever-shrinking pie of health care reimbursement. Apparently, many facilities are now taking cues from high-end hotels and are designing luxury suites for patients who can afford to pay above and beyond what their insurance covers:

A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium of McKeen [at New York-Presbyterian/Weill Cornell Hospital in New York City], leading to refurbished rooms that, like those in the hospital’s East 68th Street penthouse, cost patients $1,000 to $1,500 a day, and can be combined. That fee is on top of whatever base rate insurance pays to the hospital.

The beds are lined with expensive Italian sheets, the bathroom is outfitted with polished marble, and an army of chefs and butlers cater to the every whim of the suffering patient. New York isn’t the only place getting into the new market of posh hospital wings: many other states, mostly on the coasts, are adopting this novel approach of advertising their services to the wealthy elite, with the idea that such a strategy will enhance the cachet of the hospital and bring more of the commoners through their doors. You could call the idea “trickle-down health care.”

If I were a patient offered the type of service outlined in the NY Times article, there’s no way I’d refuse such luxurious accommodations. Who wouldn’t want 5-star treatment while recovering from an appendectomy or during the days surrounding childbirth? But as a doctor and a citizen, I’m grateful that such an environment doesn’t exist in Nebraska.

As it stands, if you come through the ER in any of the major hospitals in Omaha, you’ll receive the highest quality care regardless of your economic status. The penniless transient will be treated with the same degree of respect as Warren Buffett, and the medical care provided each would be indistinguishable. There is no elite wing of our hospitals open only to the top earners and exclusive of the other 99%.

The reason that Omaha is able to provide such egalitarian care is manifold. This region has been largely shielded from the recent economic crisis; there is a high percentage of employed and insured individuals in the area; and the mentality of the Midwest is one of global respect and relatively free of economic prejudice. While we have our share of multimillionaires among our citizenry, most are the down-to-earth self-made people who don’t expect such regal perks. All these factors conspire to create a hospital environment in this town where even the poorest residents are billeted in relative luxury during their illness (contrary to what I experienced during my training many years ago, most hospital wards nowadays have traded away the multi-patient accommodations for the more comfortable single-occupant rooms).

The move toward a tiered hospital system—with upscale arrangements for the wealthy—mirrors the type of caste scheme that has been present for years in Europe. On the surface, the socialized medicine of our Old World neighbors seems to be the epitome of egalitarianism, but the reality is somewhat different with run-down “county”-type hospitals that serve the masses and private hospitals that cater to those willing to pay a premium out of pocket. Years ago I was involved in a cycling accident while I was young, poor and living in Austria. The ambulance that picked me up never asked me where I’d like to get my care and simply dropped me off on the doorstep of the local Allgemeines Krankenhaus der Stadt Linz, the hospital subsidized by the government and meant to serve the general population. My surgery took place in a room where two other patients were being treated and I shared my hospital room with several other people. I spent 3 days in the facility with only cursory visits by my overworked doctor and finally walked out when it appeared they had no further testing or therapy for me. I never received a bill.

Across town was the elite hospital—the one the ambulance knew to avoid with someone as wretchedly poor as me. While it had no butler or personal chef, that hospital was the Austrian equivalent of the first-class suites described in the Times article. My three days of care in the commoners’ hospital were painful and miserable, but at least the experience gave me a personal introduction to the type of tiered system now popping up in our big cities.

What’s the down side to this trend? Plenty. The same hospitals that are now gearing up to attract the next Jay-Z/Beyonce baby are still doing a pretty poor job of providing service to the run-of-the-mill customer, as noted in a final anecdote by Columbia University public health professor David Rosner:

“Every generation of hospitals reflects our attitude about health and disease and wealth and poverty,” Professor Rosner said. “Today, they pride themselves on attracting private patients, and on the other hand ask for our tax dollars based upon their older charitable mission. There’s a conflict there at times.”

His perspective on McKeen’s amenities unit, where afternoon tea is served daily, is colored by the emergency room experience of one of his graduate students on the same hospital campus this month, he added. She spent two days on a gurney in terrible pain from herniated disks, he said, until a dean intervened to get her a room. “She hadn’t even been given a bed pan,” he said.

Sure, hospitals are businesses like any other. They operate on ledgers with red and black ink and have to satisfy investors and boards. If they can’t bring in enough cash then they have to go belly-up and shut their doors just like any other capitalistic enterprise. We have no problem with airlines and hotels having perks for rich people willing to pay more. Why should we bat an eye when we hear about a first-class section of the local hospital?

We probably shouldn’t. Hospitals are perfectly within their rights to build a wing that looks like a Ritz-Carlton and seeks patronage of the wealthy elite, just as the top 1% are free to pay more for 1000-thread-count Egyptian cotton linen.

Who knows? Perhaps this trend will prove so profitable that it will find its way to America’s heartland. Until then, I’m going to continue to voice my gratitude to live in a town—and work in a system—where all men and women are still considered equal.

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Kyle (first time commenter)

February 12, 2012

Reminds me of my medical school days on an Air Force scholarship in San Antonio. Back then the Air Force offered two tiers of medical care at its flagship hospital, Wilford Hall Medical Center. The top tier was called “Executive Medicine” and it provided care exclusively for generals and their dependents. Their gleaming outpatient clinic occupied an entire hospital wing on the ground floor and it was staffed by doctors who were colonels. The belief of the generals was that only the best doctors rise to the rank of colonel, therefore only colonels should take care of them. The belief of the colonels was that rubbing shoulders with generals would further their military careers.
By the time I came on active duty as an intern in that same hospital, Congress had disbanded the Executive Medicine program. I came to realize an irony as I learned the ropes of that massive hospital. The best doctors were not the colonels. They had long ago shifted their career emphasis from the practice of medicine to the pursuit of rank advancement. The best doctors were in fact the young majors! The Executive Medicine program was all about perception.

Dr. Van De Graaff

February 14, 2012

Kyle,
I recall this idea from my time in the military. The patients (the generals) thought it was a great idea because they'd get preferred service from "only the best doctors." The higher-ranking physicians loved it because they got to hobnob with the top brass.
The only problem was that it wasn't very good care. As you correctly pointed out, the most up-to-date, yet experienced, doctors were the field-grade officers, mainly the majors and lieutenant colonels. In truth, the physicians who were most attentive to details were the interns and residents. Yet none of these "lesser doctors" were allowed to get close to the military's higher echelon. If the generals had simply turned their care over to the young captains and majors like everyone else they would have had the same exceptional care military medicine is known for.
Thankfully, this idea was eventually put to rest, but probably more because of its intrinsic public relations message than the fact that it was poor care. The generals of 2012 probably wish they had the extra perks the executive medicine program offered, but they'll live longer under the current, more egalitarian system.
Thanks for your comments.
Dr. VDG

Jane

February 18, 2012

Somehow this reminded me of a movie I watched last night with my boyfriend.....Moneyball.... We loved it. It's about the politics of baseball, but exact same idea!

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Tim

August 9, 2012

I think we need to be a little realistic in using the word "equality". Equality in today's world is an illusion when it comes to most benefits, services and access to top level items. From Washington D.C. to Wall Street to hospital campuses, the "haves" will always have better access/advantages than the "have-nots". Case in point: Former V.P. Dick Cheney gets a replacement heart in a very short amount of time, while thousands of everyday people languish on donor lists. The IDEA of equality is great and it makes feel better when we think it's occurring. The REALITY is that we, as a nation, are far from equal and there is no quick solution to making it right.